Healthcare Provider Details

I. General information

NPI: 1750167706
Provider Name (Legal Business Name): MICHAEL BREAUX WALKER CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2023
Last Update Date: 09/06/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7794 PAINT CREEK DR
YPSILANTI MI
48197
US

IV. Provider business mailing address

17171 RAY ST
RIVERVIEW MI
48193-6668
US

V. Phone/Fax

Practice location:
  • Phone: 734-352-3543
  • Fax:
Mailing address:
  • Phone: 734-308-2214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: